page 1 june 28, 2011 health benefit exchange: outreach, education and enrollment delaware department...

June 28, 2011June 28, 2011

Health Benefit Exchange:Health Benefit Exchange:Outreach, Education and EnrollmentOutreach, Education and Enrollment

Delaware Department of Health and Social Services

Agenda

Introductions

Purpose of the Public Forums

Overview of the Health Benefit Exchange Who is Eligible for Coverage

What Type of Health Plans Will be Available

Outreach, Education and Enrollment Navigators – What are They

Brokers – Their Role in an Exchange

Key Decisions for Delaware

Open Discussion

Wrap-Up and Next Steps

Purpose of the Public Forums

Gather input from the public on key issues pertaining to the establishment of a Health Benefit Exchange.

Provide information to the public on the State’s approach to planning, designing and developing an Exchange for Delaware.

Today’s focus is on outreach, education and enrollment.

Your input and insight will help frame the discussion and inform the decisions going forward.

Health Benefit Exchange | What is it?

“Expedia” for health insurance:

Organized commercial health insurance marketplace for individuals and small employers Up to 50 employees in 2014, expanding to 100 employees by 2016

Enables consumers to review benefits, compare plans, and enroll in coverage

One-stop shop for publicly subsidized health coverage:

Medicaid

Delaware CHIP

New subsidies for commercial insurance

Source of information on carriers and plan performance

Health Benefit Exchange | Who is eligible for coverage?

Individual (non-group) coverage:

Legal US resident (and resident of Delaware)

Not eligible for Medicaid or Medicare

Not offered employer-sponsored insurance that is:

(1) Affordable (i.e., does not exceed 9.5% of person’s income), and

(2) meets minimum actuarial value standard of 60%

Subsidies available to individuals and families with income up to 400% of the federal poverty level (FPL) ~$43,500 for single person

~$88,200 for family of four

Health Benefit Exchange | Who is eligible for coverage?

Group coverage:

Employers with up to 50 full-time employees (FTEs) in 2014 State option to expand to 100 FTEs prior to 2016

State required to expand to 100 FTEs in 2016

State option to expand Exchange eligibility to larger groups in 2017.

Premium subsidies available to small employers with low-wage workers: 25 or fewer employees

Firm’s average wages = $50,000 or less

Tax credits -- for two years -- worth up to 50% of employer’s cost

Exchange | A Structured Marketplace

Exchange | What Type of Health Plans

“Qualified health plans” in five categories or benefit tiers:

Platinum (90%)

Gold (80%)

Silver (70%)

Bronze (60%)

High Deductible Health Plan

Coverage across these tiers will have increasing amounts of member cost sharing (e.g., co-pays, co-insurance, deductibles).


All health plans must offer “minimum essential benefits” : Ambulatory services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including

behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care


U.S. Secretary of Health and Human Services is responsible for defining “essential health benefits.”

Exchange will have flexibility -- within each coverage tier -- to determine the types of plans offered and the level of benefits (e.g., co-payments, co-insurance, deductibles).

Extent to which benefits are standardized within each tier will need to be balanced against market flexibility and creativity.

Wider variation in health plan options will require more sophisticated outreach, education, and enrollment

Exchange | Individual Shopping Experience

Exchange | Small Employer Options

Exchange | Customer Service

Exchange will need to establish customer service unit to assist people with health coverage, including call center, walk-in service centers, and web site.

Vast majority of people have likely never purchased health insurance and are not familiar with terminology and differences across plans.

Exchange’s customer service unit will need to coordinate its activities with multiple parties – including health insurers, providers, brokers, community organizations and Navigators.

Exchange | What will Navigators do

Conduct public education activities to raise awareness of the availability of qualified health plans through the Exchange;

Distribute information on enrollment and the availability of premium subsidies and cost sharing reductions;

Facilitate enrollment in qualified health plans;

Refer people to the appropriate agency if they have questions, complaints, or grievances; and

Provide information in a culturally and linguistically appropriate manner.

Exchange | Who are Navigators

Entities that have established, or can readily establish, relationships with employers, employees, consumers, and/or self-employed individuals, including, but limited to:

Trade, industry, unions and professional associations;

Chambers of commerce;

Community-based non-profits; and

Faith-based organizations.

Navigators are prohibited, by law, from receiving “direct or indirect payments” in connection with the enrollment of an individual or an employee in a health plan.

Exchange | The Role for Brokers

Health care reform law calls out brokers and agents to assist individuals and small employers enroll in qualified health plans.

U.S. Secretary of Health and Human Services is responsible for establishing procedures and guidelines pertaining to agents and brokers in the Exchange.

Given the prohibition on Navigators receiving “direct or indirect” payment in helping people enroll in a health plan, may be difficult for brokers to serve as Navigators.

Exchange | Key Decisions for Delaware

How should the health plans be structured within the five benefit tiers?

Establish standardized plan designs for each tier

Allow carriers full discretion, so long as each plan meets the requisite actuarial value

Promote market flexibility by allowing plans to offer alternative plans alongside standardized plans

How can the Exchange effectively reach the uninsured?

How can Navigators help with outreach and education?

Exchange | Key Decisions for Delaware

Who can/should serve as Navigators?

Community based organizations, Chambers of Commerce, hospitals, FQHCs

Should there be a licensing requirement for Navigators

How will brokers work through the Exchange?

What will be the responsibilities of the insurance carriers?

What type of information will people need to make informed decisions?

Will the outreach, education and enrollment needs of individuals differ from the needs of employers and employees?

Exchange | Next Steps

Public forums continue in July followed by targeted focus groups

Focus group discussions will be stakeholder driven

Next public forums:

July 12th: 4 – 6pm, Dover

July 13th: 2 – 4pm, Lewes

Forum schedule, issue briefs, and presentations are posted on the Health Care Commission’s site (dhcc.delaware.gov)

page 1 june 28, 2011 health benefit exchange: outreach, education and enrollment delaware department...

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